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Georgianos PI, Agarwal R. Resistant Hypertension in Dialysis: Epidemiology, Diagnosis, and Management. J Am Soc Nephrol 2024; 35:505-514. [PMID: 38227447 PMCID: PMC11000742 DOI: 10.1681/asn.0000000000000315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2023] [Accepted: 01/08/2024] [Indexed: 01/17/2024] Open
Abstract
Apparent treatment-resistant hypertension is defined as an elevated BP despite the use of ≥3 antihypertensive medications from different classes or the use of ≥4 antihypertensives regardless of BP levels. Among patients receiving maintenance hemodialysis or peritoneal dialysis, using this definition, the prevalence of apparent treatment-resistant hypertension is estimated to be between 18% and 42%. Owing to the lack of a rigorous assessment of some common causes of pseudoresistance, the burden of true resistant hypertension in the dialysis population remains unknown. What distinguishes apparent treatment-resistance from true resistance is white-coat hypertension and adherence to medications. Accordingly, the diagnostic workup of a dialysis patient with apparent treatment-resistant hypertension on dialysis includes the accurate determination of BP control status with the use of home or ambulatory BP monitoring and exclusion of nonadherence to the prescribed antihypertensive regimen. In a patient on dialysis with inadequately controlled BP, despite adherence to therapy with maximally tolerated doses of a β -blocker, a long-acting dihydropyridine calcium channel blocker, and a renin-angiotensin system inhibitor, volume-mediated hypertension is the most important treatable cause of resistance. In daily clinical practice, such patients are often managed with intensification of antihypertensive therapy. However, this therapeutic strategy is likely to fail if volume overload is not adequately recognized or treated. Instead of increasing the number of prescribed BP-lowering medications, we recommend diet and dialysate restricted in sodium to facilitate achievement of dry weight. The achievement of dry weight is facilitated by an adequate time on dialysis of at least 4 hours for delivering an adequate dialysis dose. In this article, we review the epidemiology, diagnosis, and management of resistant hypertension among patients on dialysis.
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Affiliation(s)
- Panagiotis I. Georgianos
- 2nd Department of Nephrology, AHEPA Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Rajiv Agarwal
- Division of Nephrology, Department of Medicine, Richard L. Roudebush Veterans Administration Medical Center, Indianapolis, Indiana
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Viazzi F, Cappadona F, Leoncini G, Ratto E, Gonnella A, Bonino B, Verzola D, Garibotto G, Pontremoli R. Two-Day ABPM-Derived Indices and Mortality in Hemodialysis Patients. Am J Hypertens 2020; 33:165-174. [PMID: 31605486 DOI: 10.1093/ajh/hpz166] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2019] [Revised: 07/14/2019] [Accepted: 10/08/2019] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Blood pressure (BP) and arterial stiffness are known cardiovascular risk factors in hemodialysis (HD) patients. This study examines the prognostic significance of 44-hour BP circadian rhythm and ambulatory arterial stiffness index (AASI) in this population. METHODS A total of 80 HD patients underwent 44-hour ambulatory BP monitoring (ABPM) with a TM-2430 monitor during a standard midweek interdialytic interval and followed up for 4.5 ± 1.7 years. The end point was all-cause mortality. RESULTS About 76% of participants were hypertensive (40% uncontrolled), 62% were nondippers, and 23% risers during the first interdialytic day, whereas 73% and 44% in the second day, respectively. During follow-up, 31 patients (40%) died. These showed higher pulse pressure (PP) and AASI44 and AASI of the second interdialytic period. The incidence of all-cause mortality was higher in HD patients with AASI44 > median, i.e. >0.54 (interquartile range = 14) (54% vs. 28%, χ 2 = 5.3, P = 0.021) when compared with those with lower AASI44. Second, but not first-day ABPM-derived parameters, namely nondipping (log-rank χ 2 = 6.10, P = 0.0134) or reverse dipping status (log-rank χ 2 = 5.32, P = 0.210) and arterial stiffness index (log-rank χ 2 = 6.61, P = 0.0101) were significantly related to greater mortality. CONCLUSIONS These findings indicate a strong relationship between arterial stiffness and cardiovascular risk and support a wider use of 44-hour ABPM recording for risk stratification in HD patients.
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Affiliation(s)
- Francesca Viazzi
- Clinica Nefrologica Dialisi e Trapianto, University of Genova and Ospedale Policlinico San Martino-IST, Genoa, Italy
| | - Francesca Cappadona
- Clinica Nefrologica Dialisi e Trapianto, University of Genova and Ospedale Policlinico San Martino-IST, Genoa, Italy
| | - Giovanna Leoncini
- Department of Internal Medicine, University of Genoa and Ospedale Policlinico San Martino, Genoa, Italy
| | - Elena Ratto
- Clinica Nefrologica Dialisi e Trapianto, University of Genova and Ospedale Policlinico San Martino-IST, Genoa, Italy
| | - Annalisa Gonnella
- Clinica Nefrologica Dialisi e Trapianto, University of Genova and Ospedale Policlinico San Martino-IST, Genoa, Italy
| | - Barbara Bonino
- Clinica Nefrologica Dialisi e Trapianto, University of Genova and Ospedale Policlinico San Martino-IST, Genoa, Italy
| | - Daniela Verzola
- Clinica Nefrologica Dialisi e Trapianto, University of Genova and Ospedale Policlinico San Martino-IST, Genoa, Italy
| | - Giacomo Garibotto
- Clinica Nefrologica Dialisi e Trapianto, University of Genova and Ospedale Policlinico San Martino-IST, Genoa, Italy
| | - Roberto Pontremoli
- Department of Internal Medicine, University of Genoa and Ospedale Policlinico San Martino, Genoa, Italy
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Georgianos PI, Agarwal R. Systolic and diastolic hypertension among patients on hemodialysis: Musings on volume overload, arterial stiffness, and erythropoietin. Semin Dial 2019; 32:507-512. [PMID: 31463996 DOI: 10.1111/sdi.12837] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Hypertension among patients on hemodialysis is predominantly systolic (either isolated or combined with diastolic hypertension), whereas the scenario of isolated diastolic hypertension is rare and more common in younger patients. Uncontrolled hypertension that persists despite aggressive antihypertensive drug therapy is a reflection of the volume overload that is a prominent mediator of systolic and diastolic BP elevation. Clinical-trial evidence supports the notion that dry-weight probing is an effective strategy to improve BP control, even when overt clinical signs and symptoms of volume overload are not present. Accelerated arterial stiffness influences the patterns and rhythms of interdialytic ambulatory BP and is a major determinant of isolated systolic hypertension in hemodialysis. Posthoc analyses of the Hypertension in Hemodialysis patients treated with Atenolol or Lisinopril (HDPAL) trial, however, suggest that arterial stiffness does not make hypertension more resistant to therapy and is unable to predict the treatment-induced improvement in left ventricular hypertrophy. A combined strategy of sodium restriction, dry-weight adjustment, and antihypertensive medication use was effective in improving ambulatory BP control regardless of the severity of underlying arteriosclerosis in HDPAL. Other nonvolume-dependent mechanisms, such as erythropoietin use, appear to be also important contributors and should be taken into consideration, particularly in younger hemodialysis patients with diastolic hypertension. In this article, we explore the role of volume overload, arterial stiffness, and erythropoietin use as causes of systolic vs diastolic hypertension in patients on hemodialysis. We conclude with clinical practice recommendations and with a call for a "volume-first" approach when managing hemodialysis hypertension.
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Affiliation(s)
- Panagiotis I Georgianos
- Section of Nephrology and Hypertension, 1st Department of Medicine, AHEPA Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Rajiv Agarwal
- Division of Nephrology, Department of Medicine, Indiana University School of Medicine and Richard L. Roudebush Veterans Administration Medical Center, Indianapolis, IN, USA
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Differential effects of arterial stiffness and fluid overload on blood pressure according to renal function in patients at risk for cardiovascular disease. Hypertens Res 2018; 42:341-353. [DOI: 10.1038/s41440-018-0151-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2018] [Revised: 06/26/2018] [Accepted: 06/27/2018] [Indexed: 12/30/2022]
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Viazzi F, Leoncini G, Ratto E, Storace G, Gonnella A, Garneri D, Bonino B, Cappadona F, Parodi EL, Verzola D, Garibotto G, Pontremoli R. Peripheral artery disease and blood pressure profile abnormalities in hemodialysis patients. J Nephrol 2016; 30:427-433. [PMID: 27250350 DOI: 10.1007/s40620-016-0322-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2016] [Accepted: 05/21/2016] [Indexed: 11/30/2022]
Abstract
BACKGROUND Patients undergoing chronic hemodialysis (HD) are at increased risk for peripheral artery disease (PAD). Both ankle-brachial index (ABI) and ambulatory blood pressure monitoring (ABPM) in the interdialytic period have been shown to be strong predictors of all-cause mortality. METHODS This cross-sectional study investigated the relationship between ABPM profile and ABI in 81 HD patients. ABPM was measured throughout a 44-h midweek interdialytic period. Pre-dialysis ABI was evaluated with a BOSO ABI device. An ABI value <0.9 or ≥1.3 was defined as abnormal. RESULTS In the whole study group (72 % males, mean age 67 ± 14 years), there was an increase in BP (p < 0.05) and in systolic BP night/day ratio (n/dSR, p = 0.01) during the interdialytic period. Patients with abnormal ABI (n = 29) more frequently had a positive history for cerebrovascular accident and PAD and higher proBNP values than those with normal ABI (n = 52). No difference was detected among ABPM-derived components except for the n/dSR (p = 0.02). Patients with abnormal ABI showed a significantly increased n/dSR (p = 0.02) and ambulatory arterial stiffness index (AASI) (p = 0.006) on the second day compared to the first. Patients with n/dSR >1 during day 2 (n = 34) were older, showed significantly higher proBNP and AASI and were more likely to reveal abnormal ABI compared to those with a lower n/dSR (p = 0.006). CONCLUSIONS Abnormal ABI in HD patients is associated to changes in interdialytic ABPM pattern, namely higher n/dSR on day 2. These data may indicate the pathophysiological mechanisms underlying the worse outcome observed in HD patients.
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Affiliation(s)
- Francesca Viazzi
- Department of Internal Medicine, University of Genova and IRCCS Azienda Ospedaliera Universitaria San Martino-IST, Viale Benedetto XV, 16132, Genoa, Italy.
| | - Giovanna Leoncini
- Department of Internal Medicine, University of Genova and IRCCS Azienda Ospedaliera Universitaria San Martino-IST, Viale Benedetto XV, 16132, Genoa, Italy
| | - Elena Ratto
- Department of Internal Medicine, University of Genova and IRCCS Azienda Ospedaliera Universitaria San Martino-IST, Viale Benedetto XV, 16132, Genoa, Italy
| | - Giulia Storace
- Department of Internal Medicine, University of Genova and IRCCS Azienda Ospedaliera Universitaria San Martino-IST, Viale Benedetto XV, 16132, Genoa, Italy
| | - Annalisa Gonnella
- Department of Internal Medicine, University of Genova and IRCCS Azienda Ospedaliera Universitaria San Martino-IST, Viale Benedetto XV, 16132, Genoa, Italy
| | - Debora Garneri
- Department of Internal Medicine, University of Genova and IRCCS Azienda Ospedaliera Universitaria San Martino-IST, Viale Benedetto XV, 16132, Genoa, Italy
| | - Barbara Bonino
- Department of Internal Medicine, University of Genova and IRCCS Azienda Ospedaliera Universitaria San Martino-IST, Viale Benedetto XV, 16132, Genoa, Italy
| | - Francesca Cappadona
- Department of Internal Medicine, University of Genova and IRCCS Azienda Ospedaliera Universitaria San Martino-IST, Viale Benedetto XV, 16132, Genoa, Italy
| | - Emanuele L Parodi
- Department of Internal Medicine, University of Genova and IRCCS Azienda Ospedaliera Universitaria San Martino-IST, Viale Benedetto XV, 16132, Genoa, Italy
| | - Daniela Verzola
- Department of Internal Medicine, University of Genova and IRCCS Azienda Ospedaliera Universitaria San Martino-IST, Viale Benedetto XV, 16132, Genoa, Italy
| | - Giacomo Garibotto
- Department of Internal Medicine, University of Genova and IRCCS Azienda Ospedaliera Universitaria San Martino-IST, Viale Benedetto XV, 16132, Genoa, Italy
| | - Roberto Pontremoli
- Department of Internal Medicine, University of Genova and IRCCS Azienda Ospedaliera Universitaria San Martino-IST, Viale Benedetto XV, 16132, Genoa, Italy
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Agarwal R, Flynn J, Pogue V, Rahman M, Reisin E, Weir MR. Assessment and management of hypertension in patients on dialysis. J Am Soc Nephrol 2014; 25:1630-46. [PMID: 24700870 PMCID: PMC4116052 DOI: 10.1681/asn.2013060601] [Citation(s) in RCA: 96] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Hypertension is common, difficult to diagnose, and poorly controlled among patients with ESRD. However, controversy surrounds the diagnosis and treatment of hypertension. Here, we describe the diagnosis, epidemiology, and management of hypertension in dialysis patients, and examine the data sparking debate over appropriate methods for diagnosing and treating hypertension. Furthermore, we consider the issues uniquely related to hypertension in pediatric dialysis patients. Future clinical trials designed to clarify the controversial results discussed here should lead to the implementation of diagnostic and therapeutic techniques that improve long-term cardiovascular outcomes in patients with ESRD.
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Affiliation(s)
- Rajiv Agarwal
- Division of Nephrology, Department of Medicine, Indiana University School of Medicine and Richard L. Roudebush Veterans Affairs Medical Center, Indianapolis, Indiana;
| | - Joseph Flynn
- Division of Nephrology, Seattle Children's Hospital, University of Washington, Seattle, Washington
| | - Velvie Pogue
- formerly Division of Nephrology, Harlem Hospital, Columbia University College of Physicians & Surgeons, New York, New York
| | - Mahboob Rahman
- Division of Nephrology and Hypertension, University Hospitals Case Medical Center, Louis Stokes Cleveland Veterans Affairs Medical Center, Case Western Reserve University, Cleveland, Ohio
| | - Efrain Reisin
- Division of Nephrology and Hypertension, Louisiana State University Health Science Center, New Orleans, Louisiana; and
| | - Matthew R Weir
- Division of Nephrology, Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland
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Agarwal R, Sinha AD, Pappas MK, Abraham TN, Tegegne GG. Hypertension in hemodialysis patients treated with atenolol or lisinopril: a randomized controlled trial. Nephrol Dial Transplant 2014; 29:672-81. [PMID: 24398888 DOI: 10.1093/ndt/gft515] [Citation(s) in RCA: 157] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND The purpose of this study was to determine among maintenance hemodialysis patients with echocardiographic left ventricular hypertrophy and hypertension whether in comparison with a β-blocker-based antihypertensive therapy, an angiotensin converting enzyme-inhibitor-based antihypertensive therapy causes a greater regression of left ventricular hypertrophy. METHODS Subjects were randomly assigned to either open-label lisinopril (n = 100) or atenolol (n = 100) each administered three times per week after dialysis. Monthly monitored home blood pressure (BP) was controlled to <140/90 mmHg with medications, dry weight adjustment and sodium restriction. The primary outcome was the change in left ventricular mass index (LVMI) from baseline to 12 months. RESULTS At baseline, 44-h ambulatory BP was similar in the atenolol (151.5/87.1 mmHg) and lisinopril groups, and improved similarly over time in both groups. However, monthly measured home BP was consistently higher in the lisinopril group despite the need for both a greater number of antihypertensive agents and a greater reduction in dry weight. An independent data safety monitoring board recommended termination because of cardiovascular safety. Serious cardiovascular events in the atenolol group occurred in 16 subjects, who had 20 events, and in the lisinopril group in 28 subjects, who had 43 events {incidence rate ratio (IRR) 2.36 [95% confidence interval (95% CI) 1.36-4.23, P = 0.001]}. Combined serious adverse events of myocardial infarction, stroke and hospitalization for heart failure or cardiovascular death in the atenolol group occurred in 10 subjects, who had 11 events and in the lisinopril group in 17 subjects, who had 23 events (IRR 2.29, P = 0.021). Hospitalizations for heart failure were worse in the lisinopril group (IRR 3.13, P = 0.021). All-cause hospitalizations were higher in the lisinopril group [IRR 1.61 (95% CI 1.18-2.19, P = 0.002)]. LVMI improved with time; no difference between drugs was noted. CONCLUSIONS Among maintenance dialysis patients with hypertension and left ventricular hypertrophy, atenolol-based antihypertensive therapy may be superior to lisinopril-based therapy in preventing cardiovascular morbidity and all-cause hospitalizations. (Funded by the National Institute of Diabetes and Digestive and Kidney Diseases; ClinicalTrials.gov number: NCT00582114).
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Affiliation(s)
- Rajiv Agarwal
- Department of Medicine, Indiana University School of Medicine and Richard L. Roudebush Veterans AdministrationMedical Center, Indianapolis, IN, USA
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Agarwal R, Light RP. Arterial stiffness and interdialytic weight gain influence ambulatory blood pressure patterns in hemodialysis patients. Am J Physiol Renal Physiol 2007; 294:F303-8. [PMID: 18160623 DOI: 10.1152/ajprenal.00575.2007] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Besides an overall increase in blood pressure, hemodialysis patients have marked disturbance in interdialytic ambulatory blood pressure pattern that is characterized by blunted circadian amplitude and a steady rise in blood pressure between dialysis treatments. The pathophysiology of this abnormal blood pressure profile is poorly understood. We hypothesized that the circadian amplitude, the interdialytic increase (linear trend), and the average level of blood pressure (the intercept) are related to the extent of arterial stiffening and the degree of accumulation of salt and water between dialysis treatments. Using a generalized cosinor model, we simultaneously compared the impact of interdialytic weight gain and echo-Doppler-measured aortic pulse wave velocity on the mean level of blood pressure, linear changes over the interdialytic interval, and oscillatory changes in blood pressure. In a cross-sectional analysis of 11,833 blood pressure measurements from 125 long-term hemodialysis patients, we found that aortic pulse wave velocity and interdialytic weight gain had a substantial impact on interdialytic ambulatory blood pressure level, trends, and rhythms. Arterial stiffness was associated with an overall increase in the level (intercept) of systolic, diastolic, and pulse pressure. Interdialytic weight gain, on the other hand, was associated with interdialytic increase (linear trend) in blood pressure. The circadian amplitude was blunted by increments in either arterial stiffness or interdialytic weight gain. Since patterns of ambulatory arterial blood pressure are related to cardiovascular risk factors such as interdialytic weight gain and increased arterial stiffness, the pattern of ambulatory blood pressure recordings may also be of prognostic significance in hemodialysis patients.
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Affiliation(s)
- Rajiv Agarwal
- Division of Nephrology, Department of Medicine, Indiana University School of Medicine, and Richard L. Roudebush Department of Veterans Affairs Medical Center, Indianapolis, Indiana 46202, USA.
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Agarwal R. How should hypertension be assessed and managed in hemodialysis patients? Home BP, not dialysis unit BP, should be used for managing hypertension. Semin Dial 2007; 20:402-5. [PMID: 17897244 DOI: 10.1111/j.1525-139x.2007.00314.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Rajiv Agarwal
- Division of Nephrology, Department of Medicine, Indiana University School of Medicine and Richard L. Roudebush VA Medical Center, Indianapolis, Indiana 46202, USA.
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Should pulse pressure and day/night variations in blood pressure be seen as independent risk factors requiring correction or simply as markers to be taken into account when evaluating overall vascular risk? DIABETES & METABOLISM 2007; 33:321-30. [PMID: 17936663 DOI: 10.1016/j.diabet.2007.04.002] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/11/2006] [Accepted: 04/20/2007] [Indexed: 12/22/2022]
Abstract
Patients with a blunted fall in nocturnal BP (known as non-dippers) have a high risk of micro- and macrovascular complications, particularly if they have hypertension, but also in normotensive patients with diabetes. A blunted fall in nocturnal BP reflects the high level of CV risk in these patients. ABPM data indicating an altered circadian BP rhythm reverse circadian BP profile should alert the physician to the potential risk of complications and should lead to efforts to treat hypertension effectively, especially at night, and to check for sleep apnoea syndrome, particularly in cases of resistant hypertension, or autonomic neuropathy (postural hypotension), a well known risk factor for cardiovascular (CV) events. Patients should be carefully screened for nephropathy. However, the definitions of "non-dipper" vary widely. Suitable treatments are poorly defined, but angiotensin-converting enzyme inhibitors (ACEi), diuretics, salt restriction and the maintenance of continuous positive airway pressure (CPAP) can be used as non-specific treatments. The efficacy of taking blood pressure-lowering drugs at bedtime rather than in the morning is still debated but deserves attention. In the diabetic population, brachial pulse pressure (PP) is an independent predictor of cardiovascular mortality, but not of all-cause mortality. It is also associated with complications of both type 2 and type 1 diabetes, this effect being stronger for nocturnal than for diurnal PP, and is strongly predictive of coronary heart disease in patients with type 2 diabetes. The stronger association between PP and age in diabetic than in non-diabetic populations suggests that diabetes accelerates vascular ageing. In patients with incipient nephropathy or overt renal failure, PP increases CV risk. However, misinterpretation could be related to confusion between brachial PP and central PP. The therapeutic implications of PP measurement remain poorly documented in diabetes.
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Agarwal R, Peixoto AJ, Santos SFF, Zoccali C. Pre- and postdialysis blood pressures are imprecise estimates of interdialytic ambulatory blood pressure. Clin J Am Soc Nephrol 2007; 1:389-98. [PMID: 17699236 DOI: 10.2215/cjn.01891105] [Citation(s) in RCA: 171] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BP readings that are obtained in the dialysis unit are commonly used to make therapeutic decisions by clinicians and to predict morbidity and mortality by epidemiologists. Dialysis unit BP are also incorporated in the recent guidelines to target BP control. The magnitude of the difference, overestimation or underestimation, and agreement between dialysis unit BP and ambulatory BP (ABP) are unknown. Articles were selected from Medline to identify those that reported both ABP and dialysis unit BP in hemodialysis patients. Bias was calculated as the difference between dialysis unit and the corresponding ABP. Agreement limits between the BP measurement techniques were assessed by pooled SD of the difference using Bland-Altman methods. Predialysis systolic BP generally overestimated ABP by a variable amount. The heterogeneity between BP measurements did not allow for pooling of the estimates. The agreement limits between the two BP was 41.7 to -25.2 mmHg. Predialysis diastolic BP also generally overestimated the ABP with wide agreement limits (23.7 to -18.9 mmHg). In contrast, postdialysis BP underestimated average ABP with wide agreement limits for both postdialysis systolic BP (33.1 to -36.3 mmHg) and diastolic BP (19.3 to -23.9 mmHg). Dialysis unit BP measurements are imprecise estimates of ABP. Better methods are needed for the assessment of BP in hemodialysis patients for clinical decision making.
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Affiliation(s)
- Rajiv Agarwal
- Division of Nephrology, Department of Medicine, Indiana University School of Medicine, and Richard L. Roudebush Veterans Affairs Medical Center, Indianapolis, Indiana 46202, USA.
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Abstract
The relationship of hypertension with adverse outcomes is uncertain in the hemodialysis population. If hypertension is an etiologically significant cardiovascular risk factor in hemodialysis patients, the first step would be to assess the level of BP accurately. BP obtained at home over a week and averaged using a validated oscillometric automatic device can prove valuable. To the extent BP lowering influences cardiovascular outcomes, home BP of 150/90 mm Hg would warrant therapy, since it correlates with target organ damage and hypertension diagnosed by ambulatory BP monitoring. To manage hypertension, limiting dietary sodium intake and individualizing dialysate sodium delivery would be first steps. The magnitude of reduction in BP with dietary sodium restriction and the whether dialysate sodium can be safely limited in those who are hypotension-prone is unclear. Antihypertensive drug therapies can effectively reduce BP and are needed by the vast majority of hemodialysis patients. Whether control of hypertension translates into better outcomes is not known, but collective evidence suggests that hypertension should be controlled in hemodialysis patients.
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Affiliation(s)
- Rajiv Agarwal
- Indiana University School of Medicine and Richard L. Roudebush Veterans Administration Medical Center, Indianapolis, Indiana 46202, USA.
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Kirkpantur A, Kahraman S, Yilmaz R, Arici M, Altun B, Erdem Y, Yasavul U, Turgan C. The Effects of Maintenance Recombinant Human Erythropoietin Therapy on Ambulatory Blood Pressure Recordings: Conventional, Doppler, and Tissue Doppler Echocardiographic Parameters. Artif Organs 2005; 29:965-72. [PMID: 16305652 DOI: 10.1111/j.1525-1594.2005.00166.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Cardiovascular disease is the major cause of mortality in maintenance hemodialysis patients. Left ventricular dysfunction is present in approximately 80% of these patients and is highly predictive of future ischemic heart disease, cardiac failure, and death. Anemia has been identified as one of several risk factors responsible for cardiac complications. The treatment of renal anemia with recombinant human erythropoietin (rHuEpo) and consequent improvement of cardiac performance may reverse pathological changes in left ventricular geometry. In this study, the acute and chronic effects of rHuEpo administration on 24-hour ambulatory blood pressure recordings and echocardiographic parameters in 30 rHuEpo-naïve maintenance hemodialysis patients were examined. Twenty-four-hour ambulatory blood pressure monitoring was performed prior to and after 1 week and 6 months of rHuEpo administration. The patients underwent echocardiographic examination prior to and after 6 months of rHuEpo administration. One week treatment with rHuEpo did not cause any significant change in 24-hour ambulatory blood pressure recordings. After 6 months of therapy, serum hemoglobin levels increased from 8.8 +/- 0.66 g/dL to 10.8 +/- 0.70 g/dL (P < 0.05). Echocardiographic examination revealed elevation in ejection fraction (62.26 +/- 6.84% vs. 69.90 +/- 8.98%, P < 0.05) with reductions in fractional shortening (36.70 +/- 4.96% vs. 35.96 +/- 6.32%, P < 0.05), interventricular septum thickness (1.21 +/- 0.16 vs. 1.00 +/- 0.16 cm, P < 0.05), and left ventricular mass index (148.2 +/- 46.5 g/m2 vs. 93.6 +/- 17.2 g/m2, P < 0.05). Doppler echocardiography and tissue Doppler imaging provided additional information in comparison with conventional echocardiography. Before treatment, mitral flow E wave (E, 0.64 +/- 0.27 vs. 0.82 +/- 0.17 cm/s), mitral flow A wave (A, 0.80 +/- 0.21 vs. 0.70 +/- 0.21 cm/s), early diastolic velocity of lateral wall (Lateral E', 11.2 +/- 2.8 vs. 12.4 +/- 2.3 cm/s), late diastolic velocity of lateral wall (Lateral A', 6.7 +/- 2.5 vs. 7.8 +/- 2.1 cm/s), early diastolic velocity of septal wall (Septal E', 9.7 +/- 2.9 vs. 11.3 +/- 1.1 cm/s), and late diastolic velocity of septal wall (Septal A', 6.4 +/- 2.1 vs. 7.8 +/- 2.0 cm/s) were significantly lower in patients than in the controls. Patients and controls have similar deceleration time of mitral flow E wave (E Dec, 186 +/- 57.8 vs. 192 +/- 62.4 ms), isovolumic left ventricular relaxation time (IVRT, 111.9 +/- 30.7 vs. 91.1 +/- 32 ms), systolic velocity of lateral wall (Lateral S', 7.8 +/- 2.3 vs. 8.1 +/- 2.0 cm/s), and systolic velocity of septal wall (Septal S', 7.5 +/- 1.9 vs. 7.7 +/- 1.4 cm/s) values. Therapy with rHuEpo did not cause significant changes in E (0.64 +/- 0.27 vs. 0.76 +/- 0.29 cm/s), A (0.80 +/- 0.21 vs. 0.79 +/- 0.23 cm/s), E Dec (186 +/- 57.8 vs. 165.8 +/- 60.1 ms), IVRT (111.9 +/- 30.7 vs. 101.6 +/- 36.2 ms), Lateral E' (11.2 +/- 2.8 vs. 11.5 +/- 4.4 cm/s), Lateral A' (6.7 +/- 2.5 vs. 7.4 +/- 2.1 cm/s), Lateral S' (7.8 +/- 2.3 vs. 8.1 +/- 2.0 cm/s), Septal E' (9.7 +/- 2.9 vs. 10.0 +/- 1.1 cm/s), Septal A' (6.4 +/- 2.1 vs. 6.6 +/- 2.0 cm/s), and Septal S' (7.5 +/- 1.9 vs. 7.9 +/- 1.4 cm/s) indicating persistence of diastolic dysfunction. In 6 months time, 24-hour ambulatory blood pressure recordings, however, tended to be higher (systolic: 125.16 +/- 21.02 mm Hg vs. 134.36 +/- 23.98 mm Hg; diastolic: 77.40 +/- 14.47 mm Hg vs. 83.26 +/- 14.89 mm Hg, P < 0.05). Correction of anemia with rHuEpo results in the elevation of blood pressure and reduction in left ventricular mass index. Myocardial contraction and relaxation velocities did not improve following regression of left ventricular hypertrophy, suggesting the persistance of diastolic dysfunction. Doppler echocardiography with tissue Doppler imaging reflects the real situation of diastolic function in patients on maintenance hemodialysis.
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Ostberg JE, Damjanovic T, Dimkovic N, Byrne D, Mikhailidis DP, Prelevic GM. Effect of tibolone on markers of cardiovascular disease risk in postmenopausal women undergoing hemodialysis: a pilot study. Fertil Steril 2004; 81:1624-31. [PMID: 15193486 DOI: 10.1016/j.fertnstert.2003.11.033] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2003] [Revised: 11/04/2003] [Accepted: 11/04/2003] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To assess the effect of tibolone on markers of vascular risk in postmenopausal women who were receiving hemodialysis. DESIGN One-year open-label study. SETTING "Zvezdara" University Medical Center, Belgrade, Serbia. PATIENT(S) Twenty-eight postmenopausal women undergoing chronic hemodialysis. INTERVENTION(S) Fifteen women received tibolone 2.5 mg three times per week; 13 other women served as controls. MAIN OUTCOME MEASURE(S) Mean arterial pressure and weight were measured at baseline and at 6 and 12 months, and blood was collected for insulin, total cholesterol, low-density lipoprotein, high-density lipoprotein, triglycerides, lipoprotein(a), high-sensitivity C-reactive protein (hs-CRP), endothelin-1 (ET-1), vascular endothelial growth factor (VEGF), and markers of renal function. RESULT(S) Mean arterial pressure fell in the tibolone but not in the control group at 6 and 12 months versus baseline (mean [SD]: 93 [15] vs. 105 [11] mmHg and 94 [10] vs. 105 [11] mmHg, respectively). Weight, insulin, lipids, lipoprotein(a), hs-CRP, ET-1, VEGF, and renal function remained unchanged within each group, but high-density lipoprotein concentrations fell in the tibolone group after 12 months (1.2 [0.3] vs. 1.6 [0.6] mmol/L). CONCLUSION(S) The effects of tibolone on markers of vascular risk in postmenopausal women who are receiving hemodialysis and healthy women appear to differ. This should be taken into account when tailoring menopausal therapies to the specific requirements of each individual.
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Affiliation(s)
- Julia E Ostberg
- Department of Medicine, Royal Free and University College Medical School, London, United Kingdom
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15
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Abstract
It is self-evident that accurate measurement of blood pressure (BP) is essential for the diagnosis and treatment of hypertension. Patients on hemodialysis typically do not have their BP measured under standardized conditions, a source of error in the assessment of their BP. However, their are some unique sources of error involving interdialytic weight gain, occurrence of sleep apnea and consequent nocturnal hypertension, inability to take BP in both arms in patients who have hemodialysis angioaccess in the arm, and the white coat effect in these patients as well. Precise measurement of BP in hemodialysis patients requires interdialytic ambulatory BP monitoring. However, when ambulatory BP monitoring is not possible, BP obtained in the dialysis unit can be used in a qualitative sense for prediction of hypertension in these patients. A 2-week average predialysis BP of greater than 150/85 mmHg or a postdialysis BP of greater than 130/75 mmHg has at least 80% sensitivity in diagnosing hypertension. Specificity of at least 80% can be achieved if predialysis BP of greater than 160/90 mmHg or postdialysis BP of greater than 140/80 mmHg are used. However, poor agreement between hemodialysis unit BP and ambulatory BP precludes their use for the precise prediction of BP. Improving measurement techniques in the dialysis unit, averaging multiple BP values, using 20-minute postdialysis readings, or home BP monitoring can improve BP determination when interdialytic BP monitoring is not possible.
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16
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Peixoto AJ, White WB. Ambulatory blood pressure monitoring in chronic renal disease: technical aspects and clinical relevance. Curr Opin Nephrol Hypertens 2002; 11:507-16. [PMID: 12187315 DOI: 10.1097/00041552-200209000-00006] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW To evaluate the current value of ambulatory blood pressure monitoring in patients with chronic renal disease and end-stage renal disease. RECENT FINDINGS Ambulatory blood pressure monitoring has become an important tool in hypertension research and clinical practice. Its use in essential hypertension shows a strong predictive ability in the assessment of cardiovascular outcomes. In chronic renal failure and end-stage renal disease, the role of ambulatory blood pressure monitoring is still being actively evaluated, and available evidence shows that it is better than office blood pressure in predicting left ventricular hypertrophy and progression of renal dysfunction in patients with chronic renal failure. In end-stage renal disease, preliminary data suggest better prediction of mortality in hemodialysis patients in comparison with clinic blood pressures. The most conspicuous problems with the literature on this subject are small sample sizes and the paucity of longitudinal observational studies and intervention trials. SUMMARY Preliminary data and extrapolations from essential hypertension have justified a growing excitement about the use of ambulatory blood pressure monitoring in renal disease. However, further research will have to address the limitations of the available literature before generalization of its use is implemented.
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Affiliation(s)
- Aldo J Peixoto
- Section of Nephrology, Yale University School of Medicine, New Haven, Connecticut, USA.
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17
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Vlassopoulos DA, Mentzikof DG, Hadjiyannakos DK, Noussias CV, Karras SM, Hadjiconstantinou VE. Long-term control of hypertension in dialysis patients by low dose atenolol. Int J Artif Organs 2002; 25:269-75. [PMID: 12027136 DOI: 10.1177/039139880202500404] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Hypertension in dialysis patients is considered a major factor in cardiovascular mortality. We investigated long-term efficacy of intermittent atenolol (AT) administration in 10 (7M/3F) hypertensive dialysis patients, age 60.5 (38-72), on dialysis for 56.5 months (8-156) thrice per week (10.5-13.5 h/w) (A). A similar group of 11 normotensive patients served as controls (B). Hypertension was defined as BP> 140/90 (day) and >120/80 mmHg (night) by a 44-h ambulatory BP monitoring (ABPM) after the mid-week session. Dialysis ultrafiltration, hematology, biochemistry were similar in A and B. Atenolol was started on an alternate day, 37.5 mg/w and increased as needed. After 34 days (6-80) and a dose of 68.75 (37.5-450) mg/w, BP dropped (ABPM: MAP 104+/-11.5 to 95.6+/-10.4 mmHg, P=0.0025) similar to controls and daytime HR dropped: 84.6+/-9.2 to 69.3+/-8.2, P=0.0008 and at night: 79.5+/-7.6 to 68.6+/-8.6 b/1' becoming lower than in B: 83+/-10.8/69.3+/-8.2, P=0.009 and 80.5+/-11.7/68.6+/-8.6 b/1' (P=0. 02). Six months later ABPM in A as well as echocardiography in A and B remained unchanged. Moderate, volume independent hypertension in stable dialysis patients is easily controlled during the interdialytic period by small intermittent atenolol doses.
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18
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Abstract
The majority of end-stage renal disease (ESRD) patients are hypertensive. Hypertension in the hemodialysis patient population is multifactorial. Further, hypertension is associated with an increased risk for left ventricular hypertrophy, coronary artery disease, congestive heart failure, cerebrovascular complications, and mortality. Antihypertensive medications alone do not adequately control blood pressure (BP) in hemodialysis patients. There are, however, several therapeutic options available to normalize BP in these patients, often without the need for additional drug therapy (eg, long, slow hemodialysis; short, daily hemodialysis; nocturnal hemodialysis; or, most effectively, dietary salt and fluid restriction in combination with reduction of dialysate sodium concentration). Optimal BP in dialysis patients is not different from recommendations for the general population, even though definite evidence is not yet available. Predialysis systolic and diastolic BPs are of particular importance. Left ventricular mass correlates with predialysis systolic BP. Survival is better in hemodialysis patients with a mean arterial pressure below 99 mm Hg as compared with those with higher BP. Low predialysis systolic BP (<110 mm Hg) and low predialysis diastolic BP (<70 mm Hg) are associated with increased mortality, primarily because of severe congestive heart failure or coronary artery disease. Patients that experience repeated intradialytic hypotensive episodes should also be viewed with caution, and predialytic BP values should be reevaluated. A possible treatment option for these patients may be slow, long hemodialysis; short, daily hemodialysis; or nocturnal hemodialysis. Among the antihypertensive agents currently available, angiotensin-converting enzyme (ACE) inhibitors appear to have the greatest ability to reduce left ventricular mass. Pressure load can be satisfactorily determined by using the average value of predialysis BP measurements over 1 month. In selected hemodialysis patients, interdialytic ambulatory blood pressure monitoring (ABPM) may help to determine if the patient is in fact hypertensive. In addition, ABPM provides important information about the change in BP between day and night. Regular home BP monitoring, yearly echocardiography, and treatment of traditional risk factors for cardiovascular disease are recommended.
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Affiliation(s)
- Matthias P Hörl
- Department of Nephrology and Rheumatology, University of Düsseldorf, Germany
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19
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Abstract
BACKGROUND There are no universally accepted criteria for the diagnosis of hypertension in hemodialysis (HD) patients. We sought to determine the clinical performance of predialysis and postdialysis systolic and diastolic blood pressure values (BPs) in diagnosing hypertension or assessing its control. METHODS Seventy patients [77% African American, 46% females, mean age 59 +/- 17 (SD) years, 34% diabetics] on chronic HD underwent a single 44-hour interdialytic ambulatory blood pressure monitoring (ABPM) and concomitant recording of BP by conventional syphygmomanometer in the HD unit for two weeks. Hypertension was defined as systolic BP (SBP) > or =135 mm Hg or diastolic BP (DBP) > or =85 mm Hg on an average 44-hour ABPM. RESULTS Average ABP was 144 +/- 22/81 +/- 11 mm Hg. Seventy-three percent of the patients had systolic hypertension; 40% had diastolic hypertension, and 24% were normotensive or had well-controlled BP. Area under the curve of receiver operating characteristic (ROC) curves exceeded 80% for all BPs, but the thresholds for best sensitivity and specificity were markedly different for predialysis and postdialysis BPs. A two-week averaged predialysis BP of > 150/85 mm Hg or a postdialysis BP of > 130/75 mm Hg had at least 80% sensitivity in diagnosing hypertension. Specificity of at least 80% was achieved if predialysis BP of > 160/90 mm Hg or postdialysis BP of > 140/80 mm Hg was used. There was poor agreement between HD unit BP and ABP values. CONCLUSIONS HD unit BP values can be used to identify the presence or absence of hypertension, although prediction of ambulatory BPs from HD unit BP values cannot be made reliably in individual patients.
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Affiliation(s)
- R Agarwal
- Department of Medicine, Indiana University and VA Medical Center, 1481 West 10th Street, Indianapolis, IN 46202, USA.
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20
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Ritz E, Schwenger V, Zeier M, Rychlik I. Ambulatory blood pressure monitoring: fancy gadgetry or clinically useful exercise? Nephrol Dial Transplant 2001; 16:1550-4. [PMID: 11477153 DOI: 10.1093/ndt/16.8.1550] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- E Ritz
- Department of Internal Medicine, Ruperto Carola University, Heidelberg, Germany
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21
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Narita I, Okada M, Omori S, Nagai M, Sawanaka N, Kondo D, Goto S, Shimada H, Shimotori T, Arakawa M, Gejyo F. The circadian blood pressure rhythm in non-diabetic hemodialysis patients. Hypertens Res 2001; 24:111-7. [PMID: 11325069 DOI: 10.1291/hypres.24.111] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
This study investigates the circadian blood pressure variation of non-diabetic chronic hemodialysis (HD) patients on both HD and non-HD days as well as the factors affecting diurnal BP variation. Forty-nine HD patients aged 61.8 +/- 12.9 years who were on daytime HD for 97 +/- 68 months were studied. No significant difference was found in every daytime and nighttime BP between the first (HD) and the second (non-HD) day. However, the ratio nighttime/daytime BP was significantly higher on the second day. Each BP diurnal variability pattern was classified as either Dipper (D: the ratio nighttime/daytime mean BP 0.8-0.9), non-dipper (0.9 < ND < 1.0), or inverted dipper (ID > 1.0). More than 75% of the cases were classified as ND (26 cases) or ID (11 cases). The ultrafiltration rate in D was significantly less than that in ND and ID. The difference of plasma renin activity between pre- and post-HD (dRen) was significantly higher in ID than in D and ND. The amount of dialysis (Kt/V) was found to be significantly correlated with nighttime BP fall. Ultrafiltration, dRen and Kt/V were independent factors for the abnormal BP diurnal variability. In conclusion, the decreased nocturnal BP fall seen in non-diabetic HD patients is associated with increased extracellular fluid even in the patients without overt overhydration, whereas relatively insufficient amount of dialysis (low Kt/V) may be another possible cause. The increased dRen observed only in ID patients may reflect occult cardiovascular damage or functional disturbances in aortic and carotid baroreflexes caused by arterial structural changes.
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Affiliation(s)
- I Narita
- Department of Medicine II, Niigata University School of Medicine, Japan
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22
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Peixoto AJ, Santos SF, Mendes RB, Crowley ST, Maldonado R, Orias M, Mansoor GA, White WB. Reproducibility of ambulatory blood pressure monitoring in hemodialysis patients. Am J Kidney Dis 2000; 36:983-90. [PMID: 11054355 DOI: 10.1053/ajkd.2000.19100] [Citation(s) in RCA: 77] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Ambulatory blood pressure monitoring (ABPM) has been increasingly used in hemodialysis (HD) practice and research; however, no study has evaluated the reproducibility of ABPM in this population. To address this question, we performed 48-hour interdialytic ABPM on 21 HD patients (mean age, 53 +/- 16 years; 7 women) on two different occasions 68 +/- 34 days (range, 30 to 154 days) apart. To qualify for the protocol, patients had to be at the same dry weight and on the same vasoactive drug regimen at both monitoring periods. BP was analyzed according to three different methods: isolated pre-HD and post-HD values, average pre-HD and post-HD values for the five HD sessions surrounding each monitoring period, and 48-hour interdialytic ABPM. Reproducibility was determined by analysis of the SD of the differences (SDD) between the two monitoring periods and the coefficient of variation of each method of BP determination. Our results show better reproducibility of ABPM (SDD, 10.6/6.6 mm Hg; coefficient of variation, 7.5%/8.1%) compared with isolated pre-HD BP (SDD, 24.4/11.3 mm Hg; coefficient of variation, 16.7%/14.1%) or post-HD BP (SDD, 16.8/14.5 mm Hg; coefficient of variation, 11.7%/17.8%), and averaged pre-HD BP (SDD, 14.7/7.2 mm Hg; coefficient of variation, 10.1%/9.1%) or post-HD BP (SDD, 12.4/8.7 mm Hg; coefficient of variation, 8.9%/11.1%). The reproducibility of the decrease in BP during sleep was poor, with up to 43% of the subjects changing dipping category within or between interdialytic periods. We conclude that ABPM is the most accurate method to study BP in HD patients over time. However, variability is significant, and there is poor reproducibility of the nocturnal decline in BP.
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Affiliation(s)
- A J Peixoto
- Sections of General Internal Medicine and Nephrology, Yale University School of Medicine, West Haven, CT, USA.
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23
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Amar J, Vernier I, Rossignol E, Bongard V, Arnaud C, Conte JJ, Salvador M, Chamontin B. Nocturnal blood pressure and 24-hour pulse pressure are potent indicators of mortality in hemodialysis patients. Kidney Int 2000; 57:2485-91. [PMID: 10844617 DOI: 10.1046/j.1523-1755.2000.00107.x] [Citation(s) in RCA: 172] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Cardiovascular (CV) complications are the leading cause of mortality in hemodialysis patients. The role of arterial hypertension on the prognosis of CV in hemodialysis patients is not as clear as in the general population. The purpose of this study was to investigate the prognostic role of ambulatory blood pressure (BP) on CV mortality in treated hypertensive hemodialysis patients. METHODS Fifty-seven treated hypertensive hemodialysis patients (56.87 +/- 16.22 years, 30 men) were prospectively studied. All patients initially underwent an ambulatory BP monitoring between two dialysis sessions. The outcome event studied was CV death; kidney transplantation and deaths not related to CV disease were censored. RESULTS The duration of follow-up was 34.4 +/- 20.39 months, during which 10 CV and 8 non-CV fatal events occurred. In the 10 patients who died from CV complications, age, previous CV events, ambulatory systolic BP, ambulatory pulse pressure (PP), and life-long smoking level were significantly higher, and the office diastolic BP was lower at the time of inclusion than in those who did not die from CV complications (N = 47). Based on Cox analysis and after adjustment for age, sex, and previous CV events, a low office diastolic BP [relative risk (RR) 0.49, 95% CI, 0.25 to 0.93, P = 0.03], an elevated 24-hour PP (RR 1.85, 95% CI, 1.28 to 2.65, P = 0.009), and an elevated nocturnal systolic BP (RR 1.41, 95% CI, 1.08 to 1.84, P = 0.01) were predictors of CV mortality (RR associated with a 10 mm Hg increase in BP and in PP). CONCLUSION This study demonstrates that nocturnal BP and 24-hour PP are independent predictors of CV mortality in treated hypertensive hemodialysis patients. Randomized trials are needed to investigate whether nocturnal BP and 24-hour PP are superior to office BP as targets for antihypertensive therapy in this high-risk group.
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Affiliation(s)
- J Amar
- Service de Médecine Interne et d'Hypertension Artérielle and Service de Néphrologie et d'Hémodialyse, CHU Purpan; and Département d'Epidémiologie, d'Economie de la Santé et de Santé Communautaire, Toulouse, France
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24
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Berns JS, Rudnick MR, Cohen RM, Bower JD, Wood BC. Effects of normal hematocrit on ambulatory blood pressure in epoetin-treated hemodialysis patients with cardiac disease. Kidney Int 1999; 56:253-60. [PMID: 10411700 DOI: 10.1046/j.1523-1755.1999.00531.x] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Hypertension is a recognized complication of partial correction of anemia with recombinant human erythropoietin (epoetin) in hemodialysis patients. We used interdialytic ambulatory blood pressure (ABP) monitoring to study the effects of partially corrected anemia versus normal hematocrit (hct) on BP in hemodialysis patients. METHODS Repeated interdialytic ABP monitoring was performed for up to one year in 28 chronic hemodialysis patients with cardiac disease who were randomized to achieve and maintain normal hct levels (42 +/- 3%, group A) or anemic hct levels (30 +/- 3%, group B) with epoetin. Routine BP measurements obtained at dialysis treatments were also evaluated. RESULTS Mean hct levels were 30.7 +/- 0.7% in group A and 30.6 +/- 0.7% in group B at baseline, then 39.3 +/- 1.2% (group A) and 33.5 +/- 0.6% (group B) at four months, and 42.0 +/- 1.1% (group A) and 30.4 +/- 1.0% (group B) at 12 months. Baseline ABP and routine dialysis unit BP levels were not different between the groups. At 2, 4, 8, and 12 months of follow-up, there were no statistically significant differences in any BP parameters between groups or increases in any BP parameters in either group A or group B patients compared with baseline. At 12 months, the mean nighttime diastolic BP (DBP) in group A patients was slightly but significantly lower than the mean daytime DBP (daytime DBP 76.6 +/- 1.9 mm Hg vs. nighttime DBP 72.9 +/- 2.1 mm Hg, P < 0.05). The mean daytime and nighttime BPs were not different from each other at two, four, and eight months in group A or at any time in group B, and in both groups, most patients had little diurnal change in BP. CONCLUSION Correction of hct to normal with epoetin in chronic hemodialysis patients with cardiac disease did not cause increased BP as assessed by interdialytic ABP monitoring or by the measurement of routine predialysis and postdialysis BP. There was little diurnal change in systolic or diastolic BP at baseline or after correction of anemia to normal levels, and although mean nighttime DBP was lower than mean daytime DBP at 12 months in group A, the maintenance of normal hct levels did not affect the abnormal diurnal BP pattern seen at moderately anemic hct levels in most patients.
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Affiliation(s)
- J S Berns
- Division of Nephrology and Hypertension, Graduate Hospital, Philadelphia, Pennsylvania 19146, USA
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